The American Surgeon™

In trauma patients using warfarin, current guidelines recommend computed tomography of the brain (CTH), 24-hour observation, and repeat CTH to monitor for stability. Despite growing evidence of uncommon delayed hemorrhage, this remains standard practice even in mild traumatic brain injury without intracranial hemorrhage (ICH). Our study sought to determine the incidence and outcomes of delayed ICH (DICH) in trauma patients on supra-therapeutic warfarin without initial ICH.

A retrospective, single institutional study was performed of all adult trauma patients (>18 years old) who presented on prehospital warfarin with an international normalized ratio (INR) >3 and initial CTH that did not demonstrate ICH. Each of these patients underwent subsequent CTH within 24 hours and any DICH was identified. Those who demonstrated DICH were further examined to identify potential risk factors and outcomes such as need for further imaging or surgical intervention. Analyses were performed using Fisher’s exact tests and Student’s t-tests.

225 patients were identified from January 2015 to April 2021 that met inclusion criteria. Of those identified, only 3 (1.33%) were found to develop any DICH on routine repeat CTH. Identified characteristics did not reach statistical significance due to the low number of DICH. None of the patients with DICH went on to require intervention.

In patients with identified traumatic injury on supra-therapeutic warfarin, an initial CTH without identified ICH alone is an adequate survey. DICH in these patients is uncommon and routine reimaging within 24 hours is unlikely to change clinical management in patients with intact neurologic status.

Trauma is an important non-obstetric cause of mortality in pregnant females.

The National Trauma Databank (NTDB) was queried between 2017 and 2018. Pregnant women >20 weeks gestation, who underwent trauma, were included. They were categorized into different age groups from 12-18, 18-35, and 36-50 years of age. The primary outcome measure was 30-day mortality.

1,058 pregnant trauma patients were included. Mean age was 26.7 ± 6 years. Of those 94.5% had blunt and 3.8% had penetrating injuries. Median GCS and ISS were 15 (15, 15) and 2 (1, 5), respectively. Penetrating trauma patients required more operative intervention (57.5%) than blunt trauma patients (24.6%). Univariate analysis comparing age groups 12-18, 19-35, and >36 years revealed differences. (P < .05) in ED systolic blood pressure (110.9 ± 19.7 vs 117.3 ± 20.3 vs 129.1 ± 29.3 mmHg, P = .01) and diabetes mellitus (.0 vs 2.7% vs 6.6% P = .03). There was no difference in HLOS (P = .72), complications (P = .279), and mortality (P = .32). Multivariate logistic regression analysis revealed that compared to patients 12-18 years old, patients 19 to 35 (P = .27) or those >36 (P = 1.0) did not show a significant difference in mortality. Patients with high ISS had higher complication rates (OR 1.09; 95% CI 1.04-1.15) and prolonged HLOS (OR 1.00; 95% CI 1.07-1.15).

On average pregnant women (>20 weeks gestation) who presented to trauma centers had minor injuries and maternal age or mechanism of injury did not affect mortality. Despite a low ISS, a significant number of these patients required operative procedures.

Validated assessment of procedural knowledge and skills with formative remediation is a foundational part of achieving surgical competency. High-fidelity simulation programs provide a unique area to assess resident proficiency and independence, as well as to assist in identifying residents in need of further practice. While several studies have validated the use of simulation to attain proficiency of specific technical skills, few have validated remediation pathways for their trainees objectively. In this descriptive analysis, we review 2 remediation pathways within our simulation training curricula and how these are used in assessments of resident proficiency.

Two methods of remediation were formulated for use in high-fidelity simulation labs. One remediation pathway was a summative process, where ultimate judgment of resident competency was assessed through intra-operative assessments of a holistic skill set. The second remediation pathway was a formative “coaching” process, where feedback is given at several intervals along the pathway towards a specific technical skills competence. All general surgery residents are enrolled in the longitudinal, simulation curricula.

Approximately one-third of surgical residents entered into a remediation pathway for either of the high-fidelity simulation curricula. Both residents and faculty expressed support for the summative and formative remediation pathways as constructed. Residents who entered remediation pathways believed it was a beneficial exercise, and the most common feedback was that remediation principles should be expanded to all residents. Interestingly, faculty demonstrated stronger support for the formative coaching feedback model than the summative assessment model.

Through the complementary use of both formative and summative remediation pathways, resident competence can be enriched in a constructive, nonpunitive method for self-directed performance improvement. Both trainees and faculty express high satisfaction with programs explicitly organized to ensure that skills are rated through a standardized process.

The incidence of organ-space surgical site infections (OSIs) across the US has not decreased to the same extent as superficial and deep surgical site infections (SSIs). This study aimed to highlight the consequences and create a predictive model of OSIs using 2019 NSQIP data.

The primary data source was the ACS NSQIP 2019 Participant Use Targeted File (PUF). Chi-squared and independent t-tests evaluated the association of OSIs and other postoperative complications. Variables of interest for our predictive model included 10 surgery types, 10 relevant preoperative laboratory values, and 26 other variables including demographics and comorbidities. A stepwise logistic regression model fit with OSIs as the outcome was used to calculate the predicted ROC and c-index.

A total of 1,076,441 cases submitted from 719 NSQIP-participating sites were included in our analysis, comprised of 16,751 (1.6%) OSIs with a median of 10 days (IQR: 11 days) between surgery and the development of an OSI. Forty-two variables were included in our final multivariable analysis. Esophageal and pancreatic surgeries yielded an approximate 4- and 6-fold higher increase in the odds of OSI, respectively (P < .001). ROC analysis yielded a c-index statistic of 0.846 (Figure 1). Associated consequences of OSIs included hospital readmission (OR = 20.74, 95% CI: 20.094-21.412, p < .001), sepsis (OR = 35.084; 95%CI: 33.75-36.47, p < .001) and higher probabilities of mortality (34% vs. 0.8%, p < .001) and morbidity (16% vs. 5.8%, p < .001).

OSIs have extensive consequences and may be predictable. These types of infections are multifactorial and require quality surveillance distinct from other SSIs.

Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs).

A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality.

Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001).

While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

The objective is to determine if injury patterns on agricultural workplaces have changed over time.

Retrospective chart review of farm trauma in Fargo, ND, from 2006 to 2020. Results were compared to historical results from La Crosse, WI, from 1978 to 1983. Patient charts with ICD location and external cause code relating to “farm” were included in the study. Frequencies and relative percentages were computed for each categorical variable. Chi-square tests were performed to determine which categories were significantly different from one another.

Injuries on farms from 395 patients from 2006 to 2020 were compared to injuries from 375 patients from 1978 to 1983. Average age of patients in 2006-2020 was 48 compared to 36 for 1978-1983. There were fewer ISS 1-9, more ISS 10-24, and similar ISS > 25 from 2006 to 2020 compared to 1978-1983. Falls doubled in 2006-2020, 132 compared to 67 in 1978-1983. Injuries from tractors were fewer in 2006-2020, and 63 compared to 89 in 1978-1983. Neurological injuries almost doubled in 2006-2020 compared to 1978-1883, 126 and 61, respectively. All the aforementioned temporal differences were statistically significant with P value < .0001. There were 9 deaths from 2006 to 2020 and 8 deaths from 1978 to 1983.

Injuries on farms today occur in older patients with higher injury severity scores and are more likely to have neurological injuries compared to data from 1978 to 1983. These changing patterns in injuries can help to provide education, direct farm safety programs, and help triage resources to critical access hospitals that care for this patient population.

Previous studies have examined how factors such as gender, education, type of training (MD or DO), and experience of the treating surgeon affect patient outcomes. We investigated patient complications after elective laparoscopic cholecystectomy based on surgeon characteristics.

A Medicare database was used to identify surgeon-specific data. The main outcome measure was the adjusted complication rates (ACR) for individual surgeons as reported by the ProPublica Surgeon Scorecard. Surgeon gender, type of training, medical school rank, years since graduation, procedure volume, and teaching status of the primary hospital affiliation were assessed for any association with increased ACR using logistic regression analysis. We explored the associations among procedure volume, years of experience, and ACR using Spearman correlation.

1107 predominantly male (94.6%) surgeons were included. 94.4% were MDs and 34.5% were affiliated with teaching hospitals. Mean length of practice was 24 ± 9 years, and median surgeon procedure volume was 28 (IQR = 23, 37). Overall median ACR was 4.3%. Multivariate analysis demonstrated that surgeon gender (P = .71), medical school rank, type of training (P = .68), or hospital affiliation (P = .77) did not have a significant impact on ACR. Increased surgeons’ years in practice (r = −.028, P = .35) and increased surgeon procedure volume (r = −.021, P = .49) were negatively associated with increased ACR.

Surgeon gender, type of training, medical school rank, or hospital affiliation had no impact on complications after laparoscopic cholecystectomy. Surgeon experience and procedure volume may have clinical implications for patient outcomes. Further studies to elucidate factors associated with surgeon quality and patient outcomes are necessary.

Patients presenting with dysphagia can encounter a pathway to therapy and relief that is expensive and frustrating. High resolution impedance planimetry (HRIP) is a new mechanism for enhancing and possibly hastening that process. A balloon with integrated pressure sensors is utilized to measure luminal geometry and pressure by volume-controlled distention. Esophagogastric junction (EGJ) distensibility and body contractility are assessed at the time of other endoscopic procedures. Here we describe a single-center experience utilizing HRIP in the endoscopic evaluation of patients presenting with dysphagia.

A prospectively maintained registry of patients undergoing impedance planimetry assessments at an academic medical center was queried for demographics, procedural details, and patient-reported outcomes.

Data was reviewed for 122 procedures performed by two providers. HRIP was performed in 63 (52%) patients for initial dysphagia assessment, 36 (30%) for follow-up assessment, and 20 (16%) as a procedural adjunct at the time of other planned procedures. HRIP contractile response was characterized as normal in 36%, absent in 32%, and diminished/disorganized in 14%. These results motivated clinical planning for surgical referral in 7 (5%) patients, 31 (26%) additional testing, and 82 (68%) continued medical management and follow-up.

HRIP is an emerging endoscopic modality which can streamline diagnostic work-up and therapeutic planning for patients with symptomatic dysphagia. Using functional esophageal assessment at the time of other diagnostic and therapeutic procedures, HRIP may expedite care and lead to improved patient satisfaction and clinical outcomes.

Regionalization efforts aim to improve healthcare by designating specialty centers for a geographic area. Regionalization may play a role in determining patient treatment plans and outcomes. We hypothesize that these factors may be influenced by race, socioeconomics, insurance, and longitudinal follow-up.

Retrospective review of 81 patients ages 0-18 years evaluated at our Level 2 Trauma Center between February 2016-December 2020 who met criteria for transfer to a Regional Burn Center.

67% of patients were transferred to the Regional Burn Center. There was no difference in the percentage of transferred patients with respect to age, race, ethnicity, insurance type, or rurality of home address. Secondary analysis showed that 57.4% of children were transferred without evaluation by social work. Five patients’ injuries were due to non-accidental trauma (NAT); two of these patients were transferred without social work evaluations. 28% of those transferred had documented involvement of Child Protective Services (CPS). Of the 31 transferred patients without social work evaluation, 67% had incomplete or missing notes from the burn center, including 100% of those subsequently confirmed to be due to NAT. Only 32% of patients received follow-up at our institution.

We identified no differences in transfer percentages with respect to race, ethnicity, or insurance type. Secondary analysis demonstrated a significant gap in care regarding access to records and social work involvement. As NAT and social concerns are common amongst children with burns, we propose policies to ensure that these concerns are not overlooked during regionalization efforts.

For critically ill congenital diaphragmatic hernia (CDH) patients on high frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and/or inhaled nitric oxide (iNO), operative repair in the neonatal intensive care unit (NICU) has been proposed to avoid complications during transport to an operating room (OR). This study compared neonates with CDH who received herniorrhaphy in the NICU or OR, with a subgroup analysis considering only patients supported with ECMO.

Patients admitted to the NICU in the first 2 weeks of life at a free-standing children’s hospital between July 2004 and September 2021 were examined. Patients were categorized according to location of CDH repair, and impact on operative complications and survival was compared.

185 patients were admitted to the NICU with posterolateral CDH and received operative repair. 48 cases were operated on at the bedside in the NICU and 137 in the OR. Patients repaired in the NICU had higher use of HFOV, pulmonary vasodilators, and ECMO (all P < .001). Children repaired in the NICU experienced significantly higher in-hospital death and overall mortality (P < .001). However, in multivariate analysis, repair location was not a significant predictor of survival to discharge in patients receiving ECMO. No significant difference in surgical site infection was detected for operative location (P = .773).

Congenital diaphragmatic hernia repair in the NICU occurred more frequently among higher risk patients who experienced worse survival. The rate of surgical site infection appeared similar overall and across subgroups suggesting adequate sterility and technique for bedside procedures, when necessary, despite restricted access to advanced operative equipment.

Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence.

We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018–12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database.

Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality.

Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

The management of isolated traumatic subarachnoid hemorrhage (itSAH) in non-trauma centers usually results in transfer to a Level 1 trauma center with neurosurgical capabilities. Due to lack of trauma center resources, we sought to evaluate if patients with itSAH need transfer to a Level I trauma center.

A retrospective review of the trauma registry was conducted from Jan 2015-Dec 2020. Patients with itSAH on initial computed tomographic imaging and a Glasgow Coma Scale score >13 were included. Patients with any other intracranial pathology, skull fractures, multi-system trauma or age less than 15 were excluded.

120 patients were identified with itSAH. Mean age was 63 years, and 44% were male. Mean injury severity score was 4.7 with 48% on anticoagulation/antiplatelet therapy. Radiology Reports were reviewed and only 2 scans (1.7%) showed an increase in itSAH, 98.3% reports revealed no change, improvement, or resolution. No patients deteriorated and no patients underwent neurosurgical intervention. Once admitted, 27 (23%) were treated for acute medical conditions and 39 (33%) required subspecialty medical consultations. There was no difference in increased itSAH on repeat imaging between patients on anticoagulation/antiplatelet therapy and those without. The population taking anticoagulant/antiplatelet therapy was older, more likely to have suffered a fall, have more comorbid conditions, was more likely to be treated for a non-traumatic medical condition and have a subspecialty medical consultation.

Patients with itSAH do not require transfer to a Level 1 trauma center for acute neurosurgical intervention.

Carbon dioxide pneumoperitoneum during laparoscopy changes cardiorespiratory physiology and contributes to post-op pain. We studied outcomes before and after implementing low-pressure pneumoperitoneum QI project.

Forty-two patients were insufflated at standard pressures (15 mmHg) while 41 were insufflated using low (8-12 mmHg) during laparoscopic procedures. These variables were obtained from the patient chart: pain scores, intravenous morphine milligram equivalents (MME), peak inspiratory pressures (PIP), end-tidal CO₂ (EtCO₂), surgery duration, and patient demographics. The study was conducted after IRB approval.

Low-pressure pneumoperitoneum is feasible and the surgeon can increase to 10-12 mmHg as needed. The mean post-op IV MME was significantly decreased in the low-pressure group (11.75 ± 10.41) compared to the standard pressure group (17.36 ± 18.1) (t-test, P = .047). Mean peak inspiratory pressures during insufflation were significantly higher for procedures conducted at standard pressure (31.40 ± 4.82) compared to the 8 mmHg (24.68 ± 4.19) and 12 mmHg (27.33± 3.85) low pressure groups (one-way ANOVA, P < .0001). During insufflation, there was a significant increase in the average EtCO₂ in the standard pressure group (42.07 ± 5.60) compared to the 8 mmHg low pressure group (37.59 ± 5.05) (ANOVA, P = .0096). Constant flow insufflation was more likely to be performed at low pressure than demand mode (58% v. 33%).

Low pressure pneumoperitoneum decreases PIP pressure and CO2 absorption evidenced by lower ETCO2 intra-operatively. Patients have significant improvement in postoperative pain evidenced by decreased narcotics needed. Low pressure pneumoperitoneum using a constant flow insufflator is safe and results in improved patient outcomes.

We sought to determine the magnitude of the inherent inter-animal physiologic variability by automating a porcine Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) protocol to minimize external influences that might alter physiology and confound experimental results.

Swine (n = 42) underwent a controlled 30% blood volume hemorrhage followed by 30 minutes of REBOA (ie, ischemic phase). The animals were weaned from REBOA autonomously over 15 minutes, beginning the reperfusion phase, while continuing to provide partial flow balloon support to maintain a target proximal mean arterial pressure (pMAP) of 65 mmHg. Simultaneously, shed blood was re-transfused as part of the resuscitation efforts. Physiologic data were continuously recorded, and serum samples were serially collected. Baseline characteristics, variance in vital signs, and 8-isoprostane levels were quantified during hemorrhage, REBOA, and reperfusion phases.

There was no significant difference in baseline physiology across animals (P > .05). Hemodynamic variability was highest for pMAP during the ischemic phase (P = .001) and for distal mean arterial pressure (dMAP) during the weaning/reperfusion phase (P = .001). The latter finding indicated the variable physiologic response to ischemia-reperfusion injury, as the automated balloon support required by each animal to maintain pMAP was highly variable. Circulating 8-isoprostane variance was significantly higher following the start of reperfusion compared to baseline levels (P = .001).

Despite subjecting animals to a highly consistent ischemia-reperfusion injury through automation, we noted significant variability in the hemodynamic and biochemical response. These findings illustrate the inherent physiologic variability and potential limitations of porcine large animal models for the study of shock.

Over the past decade, small bowel obstructions (SBO) have been increasingly managed non-operatively. Prior studies have looked at outcomes based on admission to surgical services (SS) or medicine services (MS), but most are restricted to operative patients. This study evaluates the outcomes of non-operative patients specifically.

A 12-year retrospective cohort study of patients ≥18-years-old admitted with SBO within one healthcare system was performed. Only non-operative patients were included. Clinicodemographic characteristics and admission details were extracted from the electronic medical record. Statistical analysis was performed using the student’s t-test, chi-square, and multivariable regression.

A total of 3278 patients were included, of which 933(28.4%) patients were admitted to a SS. MS patients were older (57.7 vs 54.7 years, P < .001) and more likely to have diabetes (24.1 vs 20.2%, P = .015), CHF (5.7 vs 3.1%, P = .002), and AKI (29.8 vs 16.7%, P < .001). SS patients were more likely to have cancer (19.3 vs 13.7%, P < .001). Univariate analysis showed admission to SS decreased length of stay (3.4 vs 4.1 days, P < .001) and index admission mortality (0.1 vs 2.2%, P < .001). On multivariable analysis, admission to a SS decreased admission mortality (OR 0.056), 30-day mortality (OR 0.15), and 180-day mortality (OR 0.307). Similarly, 30-day readmissions (OR 0.683) and 180-day readmission (OR 0.54) were also significantly decreased. Length of stay was decreased by .6 days (P < .001).

In patients with non-operative SBO, admission to a surgical service decreased length of stay, mortality, and readmission. Further work should be completed evaluating how increased comorbidities affect long term outcomes. However, significantly decreased length of stay and mortality continue to support surgical services admitting SBO patients.

Many factors increase the complexity of abdominal wall reconstruction including attenuated fascia, loss-of-domain, prior hernia surgeries, multiple fascial defects, enterocutaneous fistulas, and mesh infections. We describe our experience of using a suture-less mesh fixation underlay ventral herniorrhaphy technique to combat such issues in high-risk ventral hernia repair.

This is a prospective-observational study. Patients from 2019 onward undergoing emergent or elective cases were included. The technique: A large porcine acellular-dermal-matrix (ADM) alone or sutured to a light-weight, macroporous polypropylene mesh is created and placed with ADM facing the bowel. Fibrin glue is sprayed over the mesh, fascia and skin closed. An abdominal binder is placed pre-extubation and left undisturbed for 5 postoperative days.

Of 34 included patients, the average demographic was a Caucasian (62.9%) female (65.7%), with class-I or greater obesity (76.5%), hypertension (74.3%), dyslipidemia (48.6%), non-skin malignancy (40.0%), type II diabetes mellitus (34.3%), a ventral hernia working group class of III-IV (55.9%), a mean of 3 ± 2.2 prior surgeries, and mean fascial defect size of 12.3 x 13.5cm. Five were prior solid-organ transplant recipients. Four patients underwent simultaneous tumor extirpations and herniorrhaphy. Five cases (14.7%) were emergent. Removal of prior mesh was performed in 48.5% of cases—seven had infected mesh. Median length of stay was 7 days, with 141 days median follow-up time. Fifteen patients (44.1%) developed a complication. Hernia-specific complications were limited to healing problems. There were no recurrences.

This technique is easy and safe to employ in patients requiring high-risk complex abdominal reconstructions with minimal hernia-specific complications.

We previously reported the correlation between emotional intelligence (EI) with burnout/wellbeing in our PGY-1 residents, finding that EI moderated the development of burnout in the PGY-1 year. When COVID-19 arrived in early 2020, we were already collecting EI and burnout data for the 2019-2020 year. We elected to follow those residents throughout the year and compare them to the subsequent cohort to study the effect of the pandemic on their burnout and wellbeing and the influence of EI on this pattern.

All residents entering the training program (PGY-1) 2019-2020 (SURGE) & 2020-2021 (POST-SURGE) were administered the emotional intelligence questionnaire short form (TEIQue-SF), the Maslach burnout inventory, and the physician’s wellness inventory. The questionnaires were completed quarterly. Statistical analysis included ANOVA. Institutional Review Board approval was obtained prior to the study.

The overall combined PGY-1 residents year (n = 73) mean EI was 3.9 with no differences between academic year groups. The domains of burnout and physician wellbeing were examined across four different time points during the resident’s first year. Domain scores changed over the four time periods during the first year. There was a relative decrease in achievement by 3.4 points, decrease in career purpose by 1.8 points, decrease in cognitive flexibility by .6 points and increase in distress by 4.1 points. Emotional exhaustion increased significantly more for the SURGE 2019-2020 group compared to the POST-SURGE 2020-2021 group (a relative 77% change). Emotional intelligence was independently assessed within each domain at baseline and for changes over time.

Patterns of burnout and wellbeing were different with the COVID-19 SURGE group compared to the COVID-19 POST-SURGE group, perhaps because of differing expectations of the PGY-1 year participants but also perhaps due to the destabilizing effect of the first COVID-19 surge.

The current study aimed to evaluate the validity and feasibility of using a multi-sensor device to monitor patient mobility in a large postoperative population.

In this IRB-approved study, postoperative patient posture was recorded using a multi-sensor monitoring device (ViSi Mobile®) and compared with direct observations of patient physical activity. Retrospective cohort analysis of postoperative patient posture data from January to December 2019 was then performed. Patterns of postoperative mobilization were evaluated.

Multi-sensor real-time posture monitoring with the ViSi Mobile® system consistently differentiate between rest and upright posture (sensitivity and specificity, both 100%). During observation of ambulatory events, ViSi Mobile® system correctly recorded a patient’s position as upright at each validation time point in 72.7% (8 of 11) of walks. Clinical data from 562 postoperative patients were linked with posture monitoring data. Median duration of posture monitoring was 64 hours (IQR 52.5) and median number of posture positions recorded per patient was 15,370 (IQR 12,685). Median duration of upright position per day was 148.6 minutes (IQR 192.8). Duration in active upright position per day was not associated with risk of readmission (P > .05).

Real-time posture data from a multi-sensor monitoring device (ViSi Mobile®) was shown to consistently differentiate rest and active upright position. This novel technology can provide useful insight into adherence and clinical benefit of early mobilization programs.

Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality.

All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher’s exact test and continuous variables by Student’s t-test.

Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively.

Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.

Thrombocytopenia is a known surrogate marker for cirrhosis and portal hypertension and has been associated with increased risk of poor perioperative outcomes when studied in “open” operations. This study was undertaken to assess thrombocytopenia as an independent risk factor for undesirable perioperative outcomes after robotic hepatectomy.

We retrospectively reviewed 279 patients who underwent robotic hepatectomy at our institution. Patients were stratified into two cohorts based on preoperative platelet counts. Thrombocytopenia was classified as having a platelet count less than 150 /μL. Patients were 2:1 ratio propensity-score matched based on IWATE score and age. Data are presented as median (mean ± SD).

Thirty-six patients with thrombocytopenia were matched to 72 patients without thrombocytopenia. Patients with thrombocytopenia had higher MELD scores [p = 0.02] and higher Child-Pugh Scores [p <0.001]. Intraoperatively, patients with thrombocytopenia had shorter operative duration [p = 0.03] but similar estimated blood loss (EBL) [p = 0.78]. Postoperatively, there were more fresh frozen plasma transfusions in patients with thrombocytopenia [p = 0.04]. There were no differences in IWATE scores, tumor size, conversions to “open” operations, intraoperative complications, patient length of stay (LOS), Clavien-Dindo score ≥ III complications, perioperative RBC transfusion, in-hospital mortality, or 30-day readmissions.

In our propensity-score matched study, patients with thrombocytopenia had more severe liver disease; however, there were no differences in their EBL, LOS, or perioperative complications. Preoperative thrombocytopenia, while being an indicator of severity of liver disease potentially promoting perioperative bleeding, does not negatively affect the perioperative course of patients undergoing robotic hepatectomy.

This study aims to improve public health outreach in a high-risk population.

This is a single center study of Trauma Registry data, inclusive years January 1, 2016 to March 30, 2021. The study population was stratified into two groups: ETOH ≥ 80 mg/dL and ETOH <80 mg/dL. A total of 1141 were included.

Those above the legal drinking limit had a significantly higher mean ETOH (231 mg/dL; P <.01) and were typically younger men that arrived by ground ambulance. The significant injury patterns of those above the legal limit included full activation and consults who fell from stairs and fell from other or unknown. A higher proportion of intoxicated fall trauma patients above the legal limit were diagnosed with a concussion.

Excess alcohol consumption, particularly during a pandemic year, may lead to a higher incidence of fall from stairs trauma in men who are more likely to be diagnosed with a concussion.

Patients presenting with traumatic intracranial hemorrhage (ICH) routinely undergo repeat head Computed Tomography (CT) scans with the goal of identifying progressing hemorrhage early and providing timely intervention. Glasgow Coma Scale (GCS) score and Abbreviated Injury Score (AIS) are typically used to grade the severity of traumatic brain injury (TBI) and triage subsequent management. However, most patients receive a repeat head CT scan within 6 hours of the initial insult, regardless of these clinical scores. We investigated the yield of a repeat CT scan for mild blunt TBI (GCS 13-15, AIS 1-2).

This was a single-center retrospective chart review at a level 1 trauma center between 2009 and 2019. Our primary outcome was medical or surgical intervention directly resulted from change in CT head findings. We used multivariate regression to identify predictors of surgical and medical intervention.

234 mild TBI patients met inclusion criteria. 33.7% of all patients had worsening ICH. 7.7% of patients required a surgical intervention, and 27.4% received a medical intervention. Multivariate analysis found that a decline in GCS (OR 8.64), and polytrauma (Injury Severity Score >15; OR 3.32) predicted surgical intervention. Worsening ICH did not predict surgical or medical intervention. Patients requiring medical intervention were more likely to have a decline in GCS (OR 2.53, P = .02) and be older (age >65, OR 2.06, P = .02).

In the population of blunt traumatic injury, worsening ICH did not predict surgical or medical intervention. Routine repeat imaging for this population is low yield, and clinical exam should guide the decision to reimage.

Prisoners are a vulnerable population, and there are few contemporary studies that consider trauma patient outcomes within the prisoner population. Therefore, we sought to provide a descriptive analysis of prisoners involved in trauma and evaluate whether a healthcare disparity exists. We hypothesized that prisoners and non-prisoners have a similar risk of mortality and in-hospital complications after trauma.

The Trauma Quality Improvement Program (2015-2016) was queried for trauma patients based upon location inside or outside of prison at the time of injury. A multivariable logistic regression analysis was performed to compare these groups for risk of mortality—the primary outcome.

From 593,818 trauma patients, 1115 were located in prison. Compared to non-prisoners, prisoner trauma patients had no significant difference in mortality (5.1 vs 6.0%, P = .204). However, after adjusting for covariates, prisoners had a shorter length of stay (LOS) (mean days, 6.3 vs 7.8, P < .001), shorter intensive care unit (ICU) LOS (mean days, 5.44 vs 5.89, P = .004), and fewer complications, including lower rates of drug/alcohol withdrawal (.4% vs 1.1%, P = .030), pneumonia (.5 vs 1.6%, P = .004), and urinary tract infections (.0 vs 1.1%, P < .001). Upon performing a multivariable logistic regression model, prisoner trauma patients had a similar associated risk of mortality compared to non-prisoners (OR 1.61, CI .52-4.94, P = .409).

Our results suggest that prisoner trauma patients at least receive equivalent treatment in terms of mortality and may have better outcomes when considering some complications. Future prospective studies are needed to confirm these results and explore other factors, which impact prisoner patient outcomes.

Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown.

A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use.

From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI.

Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.

Limitations in available donors have dramatically reduced plasma availability over the past several decades, concurrent with increasing demand for some types of plasma. Plasma from female donors who are pregnant or taking oral contraceptives often has a green appearance, which frequently results in these units being discarded. This pilot study aimed to evaluate the hemostatic potential of green compared to standard-color plasma.

Plasma from twelve blood group-matched female and twelve male donors was obtained from the local blood center. Six of the female and all of the male units of plasma had a normal appearance (STANDARD), while six of the female units were grossly green (GREEN). The hemostatic potential was evaluated by thrombelastography (TEG), calibrated automated thrombogram (CAT), and coagulation factor level measurements. Univariate analysis was performed using Wilcoxon Rank-Sum.

GREEN plasma was more procoagulant for all TEG values (r-value, k-time, angle, mA) when compared to STANDARD plasma. Differences were also observed in coagulation factor levels, with GREEN plasma having higher than STANDARD (factors II; VII, IX; X, XI, Protein S, and plasminogen); conversely, GREEN plasma had a longer lag time in CAT.

This pilot study demonstrates that female donors with green plasma have a superior hemostatic profile than standard plasma. GREEN plasma should be further investigated for its safety profile and hemostatic potential, so if it is found to be a safe and functionally non-inferior product, it should be actively re-introduced for transfusion in bleeding patients.

The aim of this study was to determine the factors affecting procedure failure in revision thyroidectomy surgery.

A total of 148 patients applied with revision surgery were separated into 2 groups according to the surgical success status. Comparisons were made of the 2 groups of patients where residual tissue was totally excised (Group 1, n:132) and patients where residual tissue could not be completely excised (Group 2, n:16). The patients were examined in respect of factors affecting the success of the procedure.

The patients comprised 133 (89.9%) females and 15 (10.1%) males with a mean age of 49.68±12.02 years. Surgical failure was observed in 7 patients as the lesion could not be determined despite the use of intraoperative USG, and in 9 patients because of weak signal or signal loss. The determination of residual tissue ≤25mm on preoperative USG examination was seen to have a significant negative effect on surgical success (r=-0.329, p0.001). The patient having undergone ≥3 previous operations was determined to have a negative effect on surgical success (r=-0.229, p=0.005), and nerve damage on the opposite side to the lesion in a previous surgical procedure was determined to be the most important factor with a negative effect on surgical success (r=-0.571, p<0.001). In multinomial logistic regression analysis of the factors affecting success, the preoperative presence of nerve damage in the contralateral lobe to the lesion (OR: 33.11, 95% CI: 4.22-192.28, p<0.001) and lesion size ≤25 mm (OR: 10.10, 95% CI: 3.54-75.01, p=0.001) were determined to contribute significantly to surgical failure.

The results of this study clearly showed that as residual tissue size ≤25mm and contralateral nerve damage in the preoperative ultrasonographic evaluation are associated with surgical failure, alternative treatment methods such as radioactive iodine ablation may be preferred in these patients.

Food insecurity (FI) has been defined as a lack of consistent access to enough food for a healthy active lifestyle. As of 12.7% of the United States are suffering from FI, which has been correlated with increased hospital costs and poorer health outcomes. Currently, limited data exists examining the relationship between trauma populations and FI despite both having similar root causes. We sought to determine this and validate a screening tool for FI in this population.

A cross-sectional survey study of trauma patients was conducted at a level 1 trauma center in Atlanta, Georgia. Survey questions included the first two items of the Core Food Security Module. Zip codes were used to determine FI, defined by the USDA Food Access Research and compared to individual participant survey responses. Binary classification test metrics were calculated to validate the two items as a screening tool in this population.

The cohort included 136 patients, of which the majority were black (60.3%) and male (60.3%). Thirty-one respondents affirmed food security (22.8%) despite over half (51.5%) living in a food insecure community. The sensitivity and specificity for this screening to predict FI were 25 and 80%, respectively.

Although the specificity is high, this screening tool has a low sensitivity, accuracy, NPV, and PPV to determine food insecurity in this population. Community-level statistics suggests that food insecurity is a significant public problem amongst trauma patients. Prevention efforts should, therefore, aim to address both issues simultaneously.